Sunday, September 07, 2008

Recommendations by a federal task force are challenging routine preventive care practices for prostate cancer for the country's population of older men.

The guidelines, issued Monday by the U.S. Preventative Services Task Force and updated from its inconclusive stance in 2002, advise that such cancer screenings should not be performed on men aged 75 years and older. Reasons cited include a lack of strong evidence of overall benefit compared to the potential risks of screening.

In younger men, the efficacy of prostate-specific antigen (PSA) screenings remains unclear. Here, the task force advises early counseling about the risks and few benefits so men may elect not to be tested.

The study's results were published in the Aug. 5 issue of Annals of Internal Medicine. This is the first time a specific recommendation has been made on the issue.

According to Dr. Ned Calonge, chair of the 16-member task force, "the benefit of screening at this time is uncertain ... You have a chance that screening will help you live longer or better, and ... the chance that screening detection and treatment will harm you. At age 75, the chances are great that you'll have negative impacts from the screening."

Negative effects listed by the panel include psychological harm, impotency and incontinence, "additional medical visits, adverse effects of prostate biopsies, anxiety and overdiagnosis" - detection when treatment won't affect life expectancy. Some studies suggest that overdiagnosis alone can occur between 29 to 44 percent of the time.

Prostate cancer is the most common non-skin cancer in the United States and affects one out of every six men. Risk factors include family history of cancer or an African-American background.

According to the American Cancer Society, last year saw 218,890 men diagnosed with prostate cancer and about 27,050 deaths. It is the second-leading cancer killer, after lung tumors, among men. The overall mortality rate from the disease has dropped since it peaked in 1991.

Currently, one third of American men receive either PSA screenings, which test for protein blood levels, or a digital rectal exam, which identifies abnormal growth of the prostate gland. Detection enables doctors to monitor a patient whose condition is slow-growing, or to provide treatment. Some men die before their cancer even becomes an issue.

Still, the panel says their findings do not support definitive advice, and the new guidelines will not prevent a man from seeking screening and treatment for prostate cancer symptoms, such as frequent or painful urination or blood in the urine or semen.

"Larger, longer-term [clinical] studies are urgently needed," Dr. Calonge, who is also the chief medical officer for the Colorado Department of Public Health and Environment said. "We recommend that men concerned about prostate cancer talk with their health care providers to make a decision based on their individual risk factors and personal preference."

While the age limitation may be welcome for some, many doctors find the lack of strong new evidence against screening as not enough to discourage preventative care.

"The spirit of the recommendations is good, but the problem is they really do send the wrong message to older men who could have prostate cancer," said Dr. Leonard Gomella, chairman of the department of urology at Thomas Jefferson University's Kimmel Cancer Center. "This study falls short of the fact that there are older men over 75 who do need treatment."

Falling mortality rates and longer life spans around the world where PSA testing have been made available may support continued preventative care, as well.

"Men are living a lot longer these days. I play golf with 84-year-old guys who beat me all the time," Dr. E. David Crawford, a professor of surgery and radiation at the University of Colorado at Denver said to the Washington Post. "You have to individualize treatment."

"If it turns out that PSA screening and aggressive treatment saves lives, maybe all the harm that it has caused is worth it," Dr. Otis W. Brawley, chief medical officer at the American Cancer Society added. "We just don't know yet."

The PSA test was approved by the Food and Drug Administration in 1986 and has been utilized increasingly since the mid-1990s as stigmas faded, awareness grew, and screenings for other cancers such as breast and ovarian became more popular.